No. 7 or Rosie the Cow

I had my first experience of the standard ante-natal care in Dublin yesterday. I nearly avoided it due to a recent change in the hospital’s system (reaction to recent news? Maybe…) that meant that women on the Coombe’s Midwife scheme (like me) are no longer obliged to see a consultant on their second visit. However the midwives were full up so I had to push on with my visit to the Ob/Gyn Specialist. Even though I did not want to, or as far as I could tell, need to.

Photo owned by Dan Phiffer (cc)

I was seventh in line for my consultant and the place was jammers. Post it notes have a lot to answer for in this world. A post it with the mysterious marking “BR 7” was affixed to my chart and I was told room 5 or 6. No explanation was given to me about what I should expect, how I would know when it was my turn. There seemed to be about 5 consultants working. Different midwives would emerge every once in a while and call a name and a number or a name or a number. There didn’t seem to be much logic but I trusted that I would hear either my name or my number. No such luck for the couples whose English wasn’t the mae west or whose names were completely garbled by the staff. When my number was called, up I lept after the woman who called it only to find her there, gone! by the time I had gathered all my stuff. Other women present helpfully pointed me behind a curtained off area where a clatter of midwives did all the standard urine & blood pressure checks first and then proceeded to marvel at my bicycle helmet. “I’m pregnant not disabled”, I said, smiling,  “This is my third pregnancy, I think I know what I’m doing.”

While I was waiting again another consultant arrived into his rooms, all-a-fluster. He was an older guy. He went in and out again a couple of times and generally fluted about. I had been there about half an hour and he was only arriving in. I didn’t pay much attention to him until he pops his head out the door and asks the assembled women (and men), “Right who’s first? What system are we using today?” Oooh way to inspire confidence in your patients.

Thankfully he wasn’t the consultant I was visiting. It turned out my consultant wasn’t in room 5 or 6 either. So far, so fail on the instructions, hospital staff. The consultant was very nice, obviously a warm and intelligent woman, but honestly did nothing for me that all the midwives that cared for me in previous pregnancies hadn’t been more than able to do. In fact she did less because the urine and blood pressure tests had been done already. All good and 20 minutes (at most) later off we went.

Only to have to queue for 10 minutes to hand our file back in and make another appointment. At least cows get to stand in a pleasant field. And the farmer and if required the vet comes to them so as not to interrupt their valubale eating and gestating and mooing work. Of course you can sell a cow and her calf so respect is due to them. Moo.

I was going to leave it at that: a non-plussed account of a visit to a Dublin maternity hospital. But honestly my feelings on this came between me and my sleep early this morning. (That and the urgent need to pee :)) The mind just boggles about the whole system for ante-natal care in Ireland. I have decided that it is a total racket, a money-making scam. I don’t think any individuals are to blame: I think the system is flawed and possibly even corrupt.

The system as it is at the moment means that 100s of women every day have to travel to a central point to have a 20 minute appointment with someone who is over qualified for the average consultation. I do not know how the system works but I presume that the hospital gets paid per woman and obviously they get paid more if that woman visits a consultant. No doubt they get a cut and if a consultant costs say EUR100/ hour and a midwife costs EUR50/hour it doesn’t take a genius to work out why it’s better for the system to force a healthy woman to see a specialist. Please correct me if I’m wrong on these assumptions. I want to understand this system.

Then of course there are also the facilities and their upkeep. The toll that 100 women a day and their partners take on a hospital is no doubt great, no matter how well designed. While I cannot fault the staff that I have met throughout my 3 pregnancies so far, their working conditions, in Holles St., in particular are far from salubrious. Holles St make no secret about this. Naturally it is to the HSE the hospital turn seeking grants to allow them to upgrade their facilities to cater for these 1000s of women a year who are in their care.

But let’s just say for the sake of argument that 50 of those 100 women never had to go to the hospital. What if they were told that from now on all their pregnancy needs would be looked after by a midwife in their community based in the local Health Centre or a local GP’s clinic? What if from now on all these women were told that the highly trained and qualified midwife could refer them to a specialist if specialised care was required? What if these midwives visited the women in their homes, especially in the final trimester, and encouraged them to give birth in their own comfortable surroundings rather than in an uncomfortable, anonymous delivery room?

Who would gain from this arrangement? The women obviously who could arrange to meet their midwife in their home or a local centre. The benefits during labour and childbirth of being in your home or at least a familiar environment with people you know are many. The hospital could retain its facilities and specialists for those who were in actual need. Employers, who are legally obliged to give pregnant women in their employ time off to attend antenatal appointments, would gain as pregnant women would not have to take half a day off work to attend a 20 minute appointment. Who would lose? The hospitals might lose some of the justification for their capital grants and the consultants might find that they have more time to concentrate on what they are really good at and trained for – gynaecology is not just about delivering babies. Surely there are enough women experiencing difficulties  even getting pregnant to keep them busy? Heaven forfend there might even be a need for less expensive consultants and more for highly trained midwives for antenatal care! Oh and of course the anaesthethists (sp?) needed to administer epidurals would lose a gig. But of course women need epidurals because childbirth is SO painful. I think that’s a blog post for another day but let me put it like this: When the inventions that most aided women’s liberation are being discussed  the washing machine, the pill are mentioned but I have never heard anyone saying the epidural. But like I said another day!

According to the Master’s report for 2008 the Caesarean rate in the National Maternity Hospital was 19.1% in 2008. They concede that this is below the national and international standards. Their corrected perintal mortality for that year was 4.8 per thousand. These figures are indicators (by no means definitive) of the number of pregnancies that might require specialised care before, during or after birth. Granted these figures don’t include data on issues experienced by the women themselves that would require immediate medical care. I’ve heard the horror stories. Show me a pregnant woman who hasn’t heard the horror stories and I’ll show you a Martian.

The most recently published 2007 annual report for the Coombe,(PDF) even with a higher rate of Caesarean, backs up my suggestion that up to 50 women could be moved out of the hospital environment for their antenatal care. Here are the figures for obstetric outcome in 2007:

“Spontaneous vaginal delivery 59.5%
“Forceps 9.5%
“Ventouse 9.2%
“Caesarean Section 22.1%
“Induction 25.9%”

If those 44.6% of women who experienced the ventouse, forceps and induction interventions had been allowed to labour in the comfort of their own home, who knows they may have managed their labours with no intervention. Who knows? They know in Britain where Domino (Domiciliary/ In and out) is the norm. They know in Holles St. and the Rotunda and Wexford General where women can opt for the Domino.